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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL 209 1 -7697 FOR INSPECTIONS <br />EXPI S 1 YEAR FROM UATE ISSUE <br />JOB ADDRESS 1g,661 <br />} <br />LAyL <br />CITY/ZIP C4 "' <br />UL -ng <br />`• [,a- <br />CROSS STREET �l� V Vio-S <br />G <br />1 <br />OWNER NAME <br />� � <br />APN 06 <br />0 q- <br />PARCEL SIZE �r <br />F"07,f'V'--2 / 7L/ <br />L� <br />ft <br />L N F <br />OWNER ADDRESS L L C �n1 � 1l+Lu .t <br />YtD ✓P� NJCITY/STATE/ZIP <br />A ,PHON <br />1/(�C{' <br />yl it f (1 V(�l/�/ <br />CONTRACTOR VW V1 4' <br />WIDTH ft LENGTH <br />ft <br />PHONE l24 Ke, <br />ft <br />CONTRACTOR ADDRESS <br />ft FOUNDATION <br />ft PROPERTY LINE <br />CITY/STATE/ZIP A <br />❑ SUMPS <br />WIDTH ft LENGTH <br />ft <br />DEPTH <br />LICENSE ❑EIC -42 ❑0C-36 OTHER <br />NUMBER <br />EXPIRATION DATE <br />ft FOUNDATION <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: <br />❑ PERC TEST # BUILDING PERMIT## <br />TYPE OF WORK: ❑ NEW INSTALLATION X, REPAIR/ADC <br />Coordinates X Y <br />LAND USE APPLICATION ## <br />)N CI ENGINEER DESIGNED <br />11 REPLACEMENT U OUT -OF -SERVICE SEPTIC SYSTEM CI DESTRUCTION <br />INSTALLATION WILL SERVE: ❑ RESIDENCE J� COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />❑ SEPTIC TANK <br />❑ GREASE TRAP <br />❑ LIFT STATION <br />TYPE/MFG <br />TYPE/MFG <br />DISTANCE TO NEAREST: WELL <br />SIZE TYPE OF PUMP <br />CAPACITY <br />CAPACITY <br />ft FOUNDATION <br />❑ PKG TX PLANT <br />TERNATIVE <br />gal # OF COMPARTMENTS <br />gal # OF COMPARTMENTS <br />ft PROPERTY LINE ft <br />❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />❑ LEACH LINES <br />❑ LEACHING CHAMBERS <br /># OF LINES <br />LENGTH OF LINES <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ FILTER BED <br />WIDTH ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ MOUNDED <br />WIDTH ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SUMPS <br />WIDTH ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ DISPOSAL PONDS WIDTH ft LENGTH <br />ft <br />DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />❑ SEEPAGE PITS <br />NUMBER WIDTH <br />ft DEPTH <br />ft <br />DISTANCE TO NEAREST WELL <br />ft FOUNDATION <br />ft PROPERTY LINE <br />ft <br />I HEREBY CERTIFYAT <br />I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />MI U <br />8 JOUR IVANCE NOTICE REQUIRED <br />FOR INSPECTIONS - <br />kEASE CALL 209 953-7697 <br />SIGNED <br />TITLEVDATE <br />�:3 -:7-00Zi% <br />T <br />DEPARTMENT USE ONLY 01 1.� <br />Application Accepted By �j= c. Date 3 7 2 Area " Employee ID# �J <br />Final Inspection By Date ?tlZ ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br />C/O�MMENTS Ondefer k7e , e io,cen�rPh f ' k +ne Per I npP��11� -.� YU (Jor <br />PE SC Received heck# Amount Date vermlt/ <br />Code INFO B ash Remitted Service Request # <br />►; a s s g 4. 3122 S �'� � <br />X L4 <br />qqq Li Aii� �y c3 22 S 0 <br />42-01 <br />4/14/18 <br />Invoice # I Permit ID# <br />ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />